Your age grouping at the date of this
application: Under 16
16-17
18-64
65 and over
Are you legally entitled to work in Canada?
Yes
No
Do you have a reliable car?
POSITION(S) APPLIED FOR
1.
2.
Date Available:
Salary Required:
Type of Employment Desired:
Full-Time
Part-Time
Student
Temporary
Casual
Are you available
to work all shifts?
Yes
No
If no, what shifts are you
available for?
Up to 8 hours:
Days
Evenings
Nights
Weekends
Up to 12 hours:
Days
Nights
Weekends
Where are
you willing to work?
FOR NURSING ONLY
Current Ontario Certificate of Competence
Yes
No
Registration #
If not, are you eligible for registration in Ontario?
Yes
No
If not eligible, have you contacted the Ontario
College of Nurses for registration?
Yes
No
Exam Date (if applicable):
(mm/dd/yyyy)
For all In-Home Care Providers
Current CPR Certificate
Yes
No Expiry Date:
(mm/dd/yyyy)
EMPLOYMENT HISTORY Please enter your present or most recent
place of employment first and continue in sequence.
1.
Employer:
Immediate Supervisor:
Address:
Telephone:
(
)
Position:
Full Time
Part Time
Dates:
From:
To:
(mm/dd/yyyy)
Final Salary:
Total Hours Worked:
Describe duties and responsibilities - indicate
department and/or clinical area
(where applicable)
Reason for Leaving:
2.
Employer:
Immediate Supervisor:
Address:
Telephone:
(
)
Position:
Full Time
Part Time
Dates:
From:
To:
(mm/dd/yyyy)
Final Salary:
Total Hours Worked:
Describe duties and responsibilities - indicate
department and/or clinical area
(where applicable)
Reason for Leaving:
Please indicate whether or not you wish your
Present Employer contacted
Yes
No
Former Employers
Yes
No
Have you ever applied to Regional Nursing Services before?
Yes
No
If yes, when?
For what position?
Are you a former employee of Regional Nursing
Services?
Yes
No
Dates:
Position:
Reason for Leaving:
EDUCATION
SECONDARY
Course(s) of Study:
List Degree, Diploma or Grade Completed:
(Ontario equivalent):
UNIVERSITY
Course(s) of Study:
List Degree, Diploma or Grade Completed:
(Ontario equivalent):
COLLEGE OR TECHNICAL
Course(s) of Study:
List Degree, Diploma or Grade Completed:
(Ontario equivalent):
OTHER - courses,
workshops,
seminars
Course(s) of Study:
List Degree, Diploma or Grade Completed:
(Ontario equivalent):
Please list any additional courses, skills,
interests, hobbies,
special qualifications or other experiences which you feel
are relevant to the position(s) for which you are applying:
PLEASE READ CAREFULLY
I declare that the information given here to be
true and correct as far as I know, and I understand that any
misrepresentation made by me on this application shall be just and
sufficient cause for termination.
I agree to conform to the rules and regulations of
the agency while in its employ.
I agree not to disclose, either during or any time
subsequent to my employment, or authorize the disclosure of any
confidential information or knowledge concerning any matter of which
I become aware relating to patients or to the business of the agency.
I understand and accept that any salary offer is
consistent with my experience and employment history as recorded on
this application.
Date:
(mm/dd/yyyy) Signature*:
* If you are submitting
on-line, you will be required to sign this form during your interview.
We thank all applicants but wish to advise that
only those selected for an interview will be contacted.
Regional Nursing Services, 28
Fulton Way, Unit 2, Richmond Hill, Ontario L48 1J5
